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    The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients

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    Authors
    Bertges, Daniel J.
    Goodney, Philip P.
    Zhao, Yuanyuan
    Schanzer, Andres
    Nolan, Brian W.
    Likosky, Donald S.
    Eldrup-Jorgensen, Jens
    Cronenwett, Jack L.
    Vascular Study Group of New England
    UMass Chan Affiliations
    Department of Surgery
    Document Type
    Journal Article
    Publication Date
    2010-09-24
    Keywords
    Aged
    Aged, 80 and over
    Aortic Aneurysm, Abdominal
    Arrhythmias, Cardiac
    Blood Vessel Prosthesis Implantation
    Chi-Square Distribution
    Decision Support Techniques
    Endarterectomy, Carotid
    Female
    *Health Status Indicators
    Heart Diseases
    Heart Failure
    Humans
    Incidence
    Logistic Models
    Lower Extremity
    Male
    Middle Aged
    Myocardial Infarction
    New England
    Odds Ratio
    Patient Selection
    Predictive Value of Tests
    ROC Curve
    Reproducibility of Results
    Risk Assessment
    Risk Factors
    Vascular Surgical Procedures
    Surgery
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    Link to Full Text
    http://dx.doi.org/10.1016/j.jvs.2010.03.031
    Abstract
    OBJECTIVE: The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific model developed from patients within the Vascular Study Group of New England (VSGNE). METHODS: We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of 8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant predictors were converted to an integer score to create a practical cardiac risk prediction formula. RESULTS: The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia, 1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%, and 18.4% for patients with 0, 1, 2, and >or=3 risk factors. In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking (1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress test (1.2), long-term beta-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and creatinine >or=1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve = 0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72; EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and >or=6 VSG risk factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3% (score of 0-3 to 8) were discernible. CONCLUSIONS: The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making.
    Source
    J Vasc Surg. 2010 Sep;52(3):674-83, 683.e1-683.e3. Epub 2010 Jun 8. Link to article on publisher's site
    DOI
    10.1016/j.jvs.2010.03.031
    Permanent Link to this Item
    http://hdl.handle.net/20.500.14038/49767
    PubMed ID
    20570467
    Related Resources
    Link to Article in PubMed
    ae974a485f413a2113503eed53cd6c53
    10.1016/j.jvs.2010.03.031
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